By T. Riordian. Walla Walla University.

In addition discount 100mg gyne-lotrimin visa antifungal cream for jock itch in india, Chinese Research on the Treatment of Pediatric Enuresis 163 moxibustion for approximately 10 minutes was done at Guan Yuan (CV 4) and San Yin Jiao (Sp 6) until the skin was slightly red purchase gyne-lotrimin 100mg line fungus gnats all over house. One treatment was given every day, and 10 days equaled one course of treatment. Among the patients that were cured, eight cases required one course of treatment, 15 cases required two courses of treatment, and four cases required three courses of treatment. Discussion: This study is an example of combining various treatment methods to achieve better clinical results. These methods are all noninva- sive and inexpensive and can be taught to the parents of the child so they can continue to treat the child at home. From The Treatment of 100 Cases of Enuresis Using Acupuncture & Chinese Medicinals Simultaneously by Zhang Li-juan, Ji Lin Zhong Yi Yao (Jilin Chinese Medicine & Medicinals), 1992, #4, p. Treatment method: This protocol consisted of a combination of Chinese medicinals applied to the umbilicus and acupuncture. The following Chinese medicinals were applied to the navel: powdered Rou Gui (Cortex Cinnamomi), 15g Liu Huang (Sulphur), 15g Cong Bai (Bulbus Allii Fistulosi), 5-7 pieces This mixture was applied to Shen Que (CV 8) one time per day 164 Treating Pediatric Bed-wetting with Acupuncture & Chinese Medicine before sleep. In addition, acupuncture was performed at Guan Yuan (CV 4) one time each day. The patient was also allowed to use 5-7 cones of moxa or indirect ginger moxa per day as well. Study outcomes: Among these 100 cases, 88 cases were cured, four cases improved, and eight cases did not improve. Therefore, the cure rate was 88% after 4-8 treatments, and the total amelioration rate was 92%. Same disease, different treatments This section discusses treatments that have become more popu- lar in recent years. The abstracts in this section include clinical audits on the effectiveness of laser therapy, electroacupuncture, ear acupuncture, cupping, and magnet therapy. From The Treatment of 96 Cases of Pediatric Enuresis with Laser Therapy & Acupuncture by Gong Jun, Shan Xi Zhong Yi (Shanxi Chinese Medicine), 1988, #8, p. The patients were between the ages of 3-20 years old, with 89 of the cases being between 3-10 years old. The course of disease was less than one year in 34 cases, 1-3 years in 52 cases, and more than three years in 10 cases. These patients were ran- domly divided into two groups—a laser treatment group of 60 cases and an acupuncture comparison group of 36 cases. Treatment method: The main acupoints used in this protocol were: Guan Yuan (CV 4) Qi Hai (CV 6) San Yin Jiao (Sp 6) Bai Hui (GV 20). Chinese Research on the Treatment of Pediatric Enuresis 165 For lower origin vacuity cold, Shen Shu (Bl 23), Zhong Ji (CV 3), Pang Guang Shu (Bl 28), and Shui Dao (St 28) were added. If there was spleen-lung qi vacuity, Zhong Wan (CV 12), Zu San Li (St 36), Pang Guang Shu (Bl 28), and Fei Shu (Bl 13) were added. If there was liver channel damp heat, Tai Chong (Liv 3) and Yin Ling Quan (Sp 9) were added. Each time, 4-5 points were chosen and the points were alternated each time. Each point was stimulated with the laser for five min- utes, and one treatment lasted around 20 minutes. This treatment was given one time per day, and 10 days equaled one course of treatment. An interval of 7-10 days was given between each suc- cessive course of treatment. Study outcomes: The following table shows a comparison of the outcomes between the two groups. GROUP CURED MARKED IMPROVEMENT NO TOTAL IMPROVEMENT IMPROVEMENT TREATMENT 18 (30%) 20 (33. MARKED NO PATTERN CURED IMPROVEMENT IMPROVEMENT IMPROVEMENT LOWER ORIGIN VACUITY COLD 6 (18.

Also buy 100mg gyne-lotrimin mastercard fungus killing snakes, such terms as hypochondria- sis buy gyne-lotrimin 100mg antifungal medications for dogs, hysteria, or somatizing disorder would become labels that would interfere with my systematic approach. In addition, in the past I had referred such patients to psychiatrists with no benefit. Harry Abram, head of Liaison Psy- chiatry at Vanderbilt, to serve as my mentor so that I would have psychiatric backup if I got in over my head. Abram and I met 64 Symptoms of Unknown Origin on a regular basis to review the case histories until his sudden and untimely death in 1977. Premature jumps to psy- chiatric labels are not appropriate and create avoidable problems. Some of these patients ping-pong back and forth between a medi- cal doctor and a psychiatrist. Te psychiatrist, sometimes frightened by the physical symptoms, refers the patient back to the medical doctor. Over the next several years, I saw an increasing number of pa- tients with SUOs. Te patient had a hidden or obscure medical disease that explained the symptoms. Te patient had an identifiable psychosocial stress that produced the symptoms. Te patient was unknowingly ingesting, inhaling, or con- tacting a substance that produced the symptoms. Te patient had a self-induced disease that produced the symptoms or findings. Te patient denied the existence or even the possibility of any biopsychosocial stress as a cause of the symptoms. New Clinical Interventions 65 (Tese patients remained symptomatic; see Group IV in Chapter 11. In addition, the stories show the progres- sive complexity of my interventions and my increasing attention to methods of communication with the patients. In some of the sto- ries, I begin to apply the same interventions and methods of com- munication to patients with known medical diseases but whose symptoms were difficult to control. With those patients, I begin to bridge a psychological approach with medical management. Although she had never been in a psychiatric hospital, her hair was cut like most back-ward psychi- atric patients—straight bob with bangs, as you might imagine some rushed attendant would cut it. She wore a colorless smock, an oversized sweater, no stockings, and brown oxfords with low sturdy heels. My first impression was of a very disturbed woman who had just about given up on life. Florence and Sweet Ting (Chapter 8) were my first patients on my new venture into clinical medicine when I returned to Vander- bilt on the full-time faculty to run the medical teaching program at Saint Tomas Hospital. With plenty of patient-care time and no income dependence, I could test my new ideas and approaches to patients. I asked Florence why she had come to see me, and her response was that she hoped I could find out what was wrong with her. She was then see- ing at least seven specialists, including a psychiatrist. In my initial history, which took over an hour, she gave a bewildering array of com- plaints, more than thirty symptoms that covered nearly all areas of the body. I told her that I did not know what she had yet, but that I would give her my best effort to find out. I asked that she have each 66 Florences Symptoms 67 of the specialists write me a letter and send me a copy of his or her records. I drafted a letter for her and had her sign the usual release form to accompany it. Te physical examination would have to wait for the next visit—an omission that always evoked some guilt, a re- sidual of my compulsive training to do both workup and exam on the first visit.

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Water intoxication (headache cheap 100 mg gyne-lotrimin free shipping quinsana plus antifungal powder, nausea generic gyne-lotrimin 100 mg without a prescription fungus in sinuses, vom- verse reaction is water retention and hyponatremia. With lypressin, observe for headache and congestion of Adverse effects are usually mild and occur infrequently with usual nasal passages, dyspnea and coughing (if the drug is inhaled), doses. With vasopressin, observe for water intoxication; chest pain, With high doses, vasopressin constricts blood vessels, especially myocardial infarction, increased blood pressure; abdominal coronary arteries, and stimulates smooth muscle of the gastro- cramps, nausea, and diarrhea. Special caution is necessary in clients with heart disease, asthma, or epilepsy. With oxytocin, observe for excessive stimulation or con- Severe adverse reactions are most likely to occur when oxytocin tractility of the uterus, uterine rupture, and cervical and per- is given to induce labor and delivery. With octreotide, observe for arrhythmias, bradycardia, These are more common effects, especially in those receiving diarrhea, headache, hyperglycemia, injection site pain, and octreotide for acromegaly. Drugs that increase effects of vasopressin: General anesthetics, chlorpropamide (Diabinese) Potentiate vasopressin b. Drug that decreases effects of vasopressin: Lithium Inhibits the renal tubular reabsorption of water normally stimu- lated by vasopressin c. Drugs that increase effects of oxytocin: (1) Estrogens With adequate estrogen levels, oxytocin increases uterine con- tractility. What are adverse effects of the hypothalamic and pituitary Nursing Notes: Apply Your Knowledge hormones used in clinical practice? Answer: Lypressin replaces the antidiuretic hormone that acts to decrease urine output. If this medication is effective, you would SELECTED REFERENCES expect to see a decrease in urine output. Louis: Facts and less dilute (may be pale yellow rather than clear) and have a Comparisons. Philadelphia: Lippincott Williams & Review and Application Exercises Wilkins. Discuss the use of corticosteroids in selected pharmacologic doses of corticosteroids. Critical Thinking Scenario Sally, 15 years of age, was hospitalized with ulcerative colitis 2 days ago. I remember this girl in middle school who had a kidney transplant and had to take steroids. The impact a chronic illness or long-term use of corticosteroids would have for an adolescent. OVERVIEW ENDOGENOUS CORTICOSTEROIDS Corticosteroids, also called glucocorticoids or steroids, are The adrenal cortex produces approximately 30 steroid hor- hormones produced by the adrenal cortex. These hormones mones, which are divided into glucocorticoids, mineralo- affect almost all body organs and are extremely important in corticoids, and adrenal sex hormones. Glucocorticoids are maintaining homeostasis when secreted in normal amounts. Ex- Mineralocorticoids are important in maintaining fluid and ogenous corticosteroids are used as drugs in a variety of dis- electrolyte balance. Their use must be closely monitored because the drugs on normal body function. To under- Chemically, all corticosteroids are derived from choles- stand the effects of corticosteroids used as drugs, it is neces- terol and have similar chemical structures. Despite their sary to understand physiologic effects and other characteristics similarities, however, slight differences cause them to have of the endogenous hormones. Corticosterone has a small amount of activity, and ap- Corticosteroid secretion is controlled by the hypothalamus, proximately 1. Cortisone has little anterior pituitary, and adrenal cortex (the hypothalamic– activity and is secreted in minute quantities. Various stimuli (eg, low are secreted cyclically, with the largest amount being produced plasma levels of corticosteroids, pain, anxiety, trauma, ill- in the early morning and the smallest amount during the ness, anesthesia) activate the system. These stimuli cause evening hours (in people with a normal day–night schedule). CRH stimulates the anterior pituitary to se- characteristics and physiologic effects of the corticosteroids crete corticotropin, and corticotropin stimulates the adrenal (Box 24–1). The rate of corticosteroid secretion is usually maintained within relatively narrow limits but changes according to Mineralocorticoids need.

The response to a given dose Recognition and Management varies with age buy gyne-lotrimin 100mg low cost antifungal in chinese, size generic gyne-lotrimin 100 mg line fungus that causes hair loss, and renal and hepatic function. There may of Digoxin Toxicity be little difference between a therapeutic dose and a toxic dose. These factors Recognition of digoxin toxicity may be difficult because of increase the risks of dosage errors in children. In a hospital set- nonspecific early manifestations (eg, anorexia, nausea, confu- ting, institutional policies may require that each dose be veri- CHAPTER 51 DRUG THERAPY OF HEART FAILURE 753 fied with another nurse before it is administered. ECG moni- dicate higher plasma levels with HF-induced reductions in toring is desirable when digoxin therapy is started. Also, the drug and its metabolites are ex- As in adults, dosage of digoxin should be individualized creted primarily by the kidneys. Digoxin is primarily excreted by the With milrinone, which is also excreted primarily by the kid- kidneys, and dosage must be reduced with impaired renal neys, renal impairment significantly increases elimination half- function. In general, divided daily doses should be given to life, drug accumulation, and adverse effects. Larger doses are usually needed to slow a too-rapid ventricular rate in children with atrial fibrillation or flutter. Differences in bioavailability of different preparations Use in Hepatic Impairment (parenterals, capsules, elixirs, and tablets) must be considered when switching from one preparation to another. Hepatic impairment has little effect on digoxin clearance, and Neonates vary in tolerance of digoxin depending on their no dosage adjustments are needed. Premature infants are especially sensitive metabolized in the liver and may be hepatotoxic. Dosage must be reduced, and digitalization increases in liver enzymes and clinical symptoms occur, in- should be even more individualized and cautiously ap- amrinone should be discontinued. If smaller increases in liver proached than in more mature infants and children. Early enzymes occur without clinical symptoms, inamrinone may signs of toxicity in newborns are undue slowing of sinus rate, be continued with reduced dosage or discontinued, depending sinoatrial arrest, and prolongation of the PR interval. Use in Critical Illness Use in Older Adults Critically ill clients often have multiple cardiovascular and Digoxin is widely used and a frequent cause of adverse ef- other disorders that require drug therapy. It may also be precipitated by because of decreased liver or kidney function, decreased lean other illnesses or treatments that alter fluid balance, impair body weight, and advanced cardiovascular disease. All of myocardial contractility, or increase the workload of the heart these characteristics are common in older adults. Management is often renal function leads to slower drug excretion and increased symptomatic, with choice of drug and dosage requiring care- risk of accumulation. All of the drugs should be used with caution in criti- increase serum digoxin levels and increase risks of toxicity if cally ill clients. Antacids decrease absorption of oral digoxin and should not be given at the same time. Herbal and Dietary Supplements Use of nonprescription herbal and dietary supplements is fre- Use in Renal Impairment quently not reported by the client even though one third of the adults in the United States use these agents. Significant inter- Digoxin should be used cautiously, in reduced dosages, be- actions can occur between supplements and prescribed drugs. Both loading and Ephedra may increase cardiac stimulation and worsen dys- maintenance doses should be reduced. Natural licorice blocks the effects of spironolac- renal impairment can achieve therapeutic serum concentra- tone and causes sodium retention and potassium loss, effects tions with a dosage of 0. Hawthorn should be used cautiously as it may in- neys (eg, fluid volume depletion or acute HF), digoxin may crease the effects of ACE inhibitors and digoxin. Clients may utilize herbs creted through the kidneys and maintenance doses may need such as dandelion root and juniper berries for their diuretic even greater decreases than those calculated according to cre- effect. Thus, digoxin toxicity develops more often instead of prescribed drug therapies. Clients with renal im- pairment who are receiving digoxin, even in small doses, should be monitored closely for adverse effects, and serum Home Care digoxin levels should be monitored periodically. There is no information available about the use of inamri- Most digoxin is taken at home, and the home care nurse shares none in renal impairment. However, pharmacokinetic data in- responsibility for teaching clients how to use the drug effec- 754 SECTION 9 DRUGS AFFECTING THE CARDIOVASCULAR SYSTEM tively and circumstances to be reported to a health care tions and produce different responses. Accurate dosing is vitally important because under- together to be more effective and maintain a more balanced use may cause recurrence of symptoms and overuse may state of cardiovascular function.

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